2015 TERTIARY EDUCATION GRANT APPLICATION FORM
CLOSING DATE: Tuesday 31 March 2015 at 4.00pm
PLEASE SEND APPLICATIONS TO:
Postal Address: PO Box 227
Whakatane
Contact Info:
Telephone (07) 929 5690
Email: [email protected]
Physical Address: Omataroa Rangitaiki No 2 Trust
Te Wairere House
6 Wairere Street
Whakatane
OFFICE USE ONLY:
Date Received:
/
/
Applicants First Name:
Last Name
Email:
Enrolment Verified:
Yes
No
Tax Invoice Received:
Yes
No
Whakapapa Verified:
Yes
No
Name of Current Shareholder Correct:
Yes
No
Shareholder Registration No: Identified:
Yes
No
Bank Account Verified:
Yes
No
Yes
No
Total Fees:
$
Current Shareholder Name:
Registration Completed:
Comment:
TERTIARY GRANT POLICY
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EDUCATIONAL ASSISTANCE
1.1 Grants are available to Owners or a Natural Issue of an Owner who are studying at a recognized
tertiary education institution.
1.2 Grants and scholarships are available for fulltime and part-time study.
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AWARDING OF GRANTS
In determining educational awards, Trustees will also consider the following circumstances:
2.1 The amount of total fees levied by the Tertiary Institution.
2.2 A brief written statement covering the following:
a) Commitments by members of your Whanau to assist you in your academic studies
b) Your own contributions, past, present or future towards the general well-being of your Whanau,
Hapu and Iwi
c) Any other special circumstances
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APPROVAL OF GRANTS
3.1 All applications will be referred to the Grants Sub-Committee for assessment.
3.2 Grants approved will be paid in two equal instalments as follows:
a) Instalment 1 upon approval of grant
b) Instalment 2 upon production of certified results from the Tertiary Institution for the current study
period
c) Second Instalment will be due for payment by the end of March 2016
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ADDITIONAL INFORMATION
4.1 The tenure of the grant shall be for one year only. Applicants must submit a new application each year.
4.2 Closing date for applications will be Tuesday 31 March 2015 at 4.00pm.
4.3 Incomplete and late applications will not be considered.
4.4 Grants will contribute towards tuition fees only.
4.5 If an applicant withdraws from their course or individual papers prior to receiving funding, or after
receiving funding they must notify the Trust. If this does not occur, an applicant may not be eligible for
further grants.
4.6 The Trust reserves the right to use a successful applicants name and other details for publicity and
promotion purposes.
4.7 The Trustees have the sole discretion to accept or decline any application that does not meet grant
criteria.
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SECTION 1: APPLICANT DETAILS
First Name:
Middle Name:
Surname:
Gender:
Male
Date of Birth:
Female
/
/
Age:
SECTION 2: APPLICANT POSTAL DETAILS
Postal Address:
Post Code:
Phone (Day):
(
)
Cell phone No: (
)
Email Address:
SECTION 3: APPLICANT BANK ACCOUNT DETAILS
BANK ACCOUNT
BANK ACCOUNT NAME:
(Applicant Account)
BANK ACCOUNT NUMBER:
Once you have completed the above details please attach a Bank generated deposit
slip.
Bank Verified Stamp
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SECTION 4: EDUCATION DETAILS
Tertiary Institution:
Address:
Telephone:
(
)
Fax Number: (
)
Email Address
SECTION 5: COURSE DETAILS
Course of Study:
Course Duration:
Start Date:_______________
End Date:_________________
Level of Qualification
(Please tick relevant box)
Bachelor Degree
Certificate
Conjoint Degree
Diploma
Masters
P.H.D
Post Graduate Degree
Other: (Please State)
2015 Year of Study
(Please tick relevant box)
1 year
2015 Type of Study
(Please tick relevant box)
Full Time
2 year
3 year
4 year
5 year
6 year
Part Time
CHECKLIST
Confirmation of Enrolment
Please attach:
 Letter of acceptance, dated this year, from Institute stating study being undertaken and period of enrolment
Student Fees
Please attach:
 A copy of the STUDENTS INVOICE, dated this year, verifying the fees charged relating to the students
2015 enrolment as confirmed above.
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SECTION 6: WHAKAPAPA DETAILS
Please show clearly that you are a current shareholder OR a descendant of a current shareholder of Omataroa
Rangitaiki No 2 Trust
SECTION 6.1: SHAREHOLDER DETAILS
If this information is inaccurate or incomplete your application will be declined
1. Applicant must be a current shareholder or a direct descendant of a current shareholder
2. The name of the Shareholder must correspond with the name of a Current Owner in Trust.
(Please refer to the Maori Land Court Website @ www.maorilandonline)
3. Current Shareholder must register their contact details with the Trust by completing a Registration Form.
(OMR2 Shareholder Registration Forms are available from the Office)
4. Please ensure that you have correctly entered the Shareholders Registration No: Do not leave this blank or use
an incorrect number as your application may be considered incomplete: We advise students to contact
the office if shareholder number is unknown.
Current Shareholder Name: (Individual)
(if applicable)
Current Shareholder Name: (Whanau Trust)
(if applicable)
Shareholder Registration No:
(Contact the office if unknown)
SECTION 6.2: WHAT IS YOUR RELATIONSHIP TO THE SHAREHOLDER (TICK ONE)
I am the Shareholder
OR
The Shareholder is my
My Parent
My Grandparent
My Great Grandparent
The Shareholder is a Whanau Trust
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SECTION 6.3: WHAKAPAPA DETAILS
Provide the side of the whakapapa which includes the shareholder
TUPUNA OF WHANAU TRUST
(IF APPLICABLE)
GREAT GRANDPARENT:
GRANDPARENT:
PARENT:
APPLICANT:
KAUMATUA VERIFICATION:
I ..............................................................................(name) do hereby confirm that the above Whakapapa details
are true and correct.
Signed: ----------------------------------------------------------
WHANAU TRUST: TRUSTEE VERIFICATION
If the current shareholder is a Whanau Trust, a trustee must also confirm both the identity of the student and
their Whakapapa to the Whanau Trust.
I ..............................................................................(name) am a Trustee of the Whanau Trust do hereby confirm
the applicant is a beneficiary of the Trust.
Signed: ----------------------------------------------------------
CHECKLIST
Whakapapa Verification
This must be signed by a Kaumatua who can confirm both the identity of the student and whakapapa to a current
shareholder in Omataroa Rangitaiki No 2 Trust. If the student is an owner, this section must still be signed as it is to
verify the students’ identity
Shareholder Registration No
Please ensure your have correctly entered the Shareholders Registration Number on Page 5 of this application. Do
not leave this blank or use an incorrect number as your application may be considered incomplete: We advise
students to contact the office if shareholder number is unknown.
Whanau Trusts: Trustee Verification
A trustee must also confirm both the identity of the student and their whakapapa to the Whanau Trust.
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SECTION 7: PERSONAL STATEMENT
7.1 Commitment by members of your Whanau to assist you in your academic studies:
7.2 Your own contributions, past, present or future towards the general well-being of your Whanau, Hapu and Iwi:
7.3 Any other special circumstances
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SECTION 8: DECLARATION
I hereby certify that the information in this application form is correct, and that my application may be cancelled (without
right of review) if the information supplied is incomplete, inaccurate or not supplied by due date.
I consent to any of this information being made available to Omataroa Rangitaiki No 2 Trust for statistical purposes, and for
my name to be used as a Successful Grant Recipient for publicity and promotion purposes.
I consent to the Tertiary Institution with which I am enrolled releasing any information required concerning my application
form to Omataroa Rangitaiki No 2 Trust in accordance with the Privacy Act 1993 and the Education Act 1989.
I consent to Omataroa Rangitaiki No 2 Trust contacting any Agencies to verify that information provided in this application
is true and correct, in accordance with the Privacy Act 1993.
Signature
Date
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CHECKLIST
Please remember to complete & attach the following documentation
Bank Account Verification
The student’s bank account must be verified by a bank generated deposit slip.
Confirmation of Enrolment
Please attach:
 Letter of acceptance, dated this year, from Institute stating study being undertaken and period of
enrolment
Student Fees
Please attach:
 A copy of the STUDENTS INVOICE, dated this year, verifying the fees charged relating to the students
2015 enrolment as confirmed above.
Personal Statement
Student must complete their Personal Statement
Whakapapa Verification
This must be signed by a Kaumatua who can confirm both the identity of the student and whakapapa to a
current owner in Omataroa Rangitaiki No 2 Trust. If the student is an owner, this section must still be signed as
it is to verify the students’ identity.
Whanau Trusts: Trustee Verification
If the current shareholder is a whanau trust, a trustee must also confirm both the identity of the student and
whakapapa to the whanau trust.
Shareholder Registration No
Please ensure your have correctly entered the Shareholders Registration Number on Page 5 of this application.
Do not leave this blank or use an incorrect number as your application may be considered incomplete: We
advise students to contact the office if shareholder number is unknown.
Declaration
Declaration must be signed by the Student
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ACKNOWLEDGEMENT RECEIPT
2015 TERTIARY GRANT
NAME:
POSTAL
ADDRESS:
OFFICE USE ONLY
Tena Koe
Thank you for your grant application.
Your application:
Has met all requirements and is referred to the Grants Committee for final approval
Is incomplete and will not be considered. The reasons are:
 Did not verify bank account details
 Did not provide verification of Enrolment
 Did not provide a copy of the students 2015 fees invoice
 Did not complete personal statement
 Did not meet Whakapapa Requirements
 Did not complete Whakapapa Section
 Did not sign Declaration
Application was received after due date, and will not be considered
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